20:06:13:32. Requirements
concerning application forms and replacement coverage. Application forms
must include the following statements and questions which are designed to
elicit information as to whether, as of the date of the application, the
applicant currently has Medicare supplement, Medicare Advantage, Medicaid
coverage, or another health insurance policy or certificate in force, or
whether a Medicare supplement policy or certificate is intended to replace any
other accident and sickness policy or certificate presently in force. A
supplementary application or other form to be signed by the applicant and agent
containing such questions and statements may be used. Unless coverage is direct
marketed, the agent must ask and record the answers to all questions on the
forms. In the case of a direct response issuer, a copy of the application or
supplemental form, signed by the applicant and acknowledged by the issuer, must
be returned to the applicant by the issuer upon delivery of the policy.

In lieu of the agent's recording all
of the applicant's responses, an insurer may record or make contractual
arrangements for persons other than agents to record the applicant's responses.
Prior to issuance of coverage, the insurer, agent, or contractor involved in the
application process must ask all remaining application questions and such
persons must accurately record the applicant's responses to each of the
applicable questions in the application. The insurer is responsible for any
failure to ask and accurately record the applicant's responses to each
applicable question. The privacy requirements outlined in chapter 20:06:45 and
the Medicare Supplement marketing restrictions outlined in § 20:06:13:58
apply to such arrangements.

Nothing in this section may be construed
to prohibit the insurer from denying an incomplete application or to require
that further questions be asked of the applicant once the response to a
question clearly indicates the applicant is ineligible for coverage.

Nothing in this section in any way
modifies the requirement for a person to hold an insurance agent license if
that person sells, solicits, or negotiates Medicare Supplement insurance or any
other kind of insurance.

While assisting the applicant, a
non-licensed person is prohibited from attempting to sell or to interest the
applicant in purchasing any product, insurance related or otherwise.

The required statements and questions
are as follows:

STATEMENTS

(1) You do not need more
than one Medicare supplement policy.

(2) If you purchase this
policy or certificate, you may want to evaluate your existing health coverage
and decide if you need multiple coverages.

(3) You may be eligible for
benefits under Medicaid and may not need a Medicare supplement policy.

(4) If, after purchasing
this policy, you become eligible for Medicaid, the benefits and premiums under
your Medicare supplement policy can be suspended, if requested, during your
entitlement to benefits under Medicaid for 24 months. You must request this
suspension within 90 days after becoming eligible for Medicaid. If you are no
longer entitled to Medicaid, your suspended Medicare supplement policy (or, if
that is no longer available, a substantially equivalent policy) will be
reinstituted if requested within 90 days after losing Medicaid eligibility. If
the Medicare supplement policy provided coverage for outpatient prescription
drugs and you enrolled in Medicare Part D while your policy was suspended, the
reinstituted policy will not have outpatient prescription drug coverage, but
will otherwise be substantially equivalent to your coverage before the date of
the suspension;

(5) If you are eligible
for, and have enrolled in a Medicare supplement policy by reason of disability
and you later become covered by an employer or union-based group health plan,
the benefits and premiums under your Medicare supplement policy can be
suspended, if requested, while you are covered under the employer or
union-based group health plan. If you suspend your Medicare supplement policy
under these circumstances, and later lose your employer or union-based group
health plan, your suspended Medicare supplement policy or if that is no longer
available, a substantially equivalent policy will be reinstituted if requested
within 90 days of losing your employer or union-based group health plan. If the
Medicare supplement policy provided coverage for outpatient prescription drugs
and you enrolled in Medicare Part D while your policy was suspended, the
reinstituted policy will not have outpatient prescription drug coverage, but
will otherwise be substantially equivalent to your coverage before the date of
the suspension.

(6) Counseling services may
be available in your state to provide advice concerning your purchase of
Medicare supplement insurance and concerning medical assistance through the
state Medicaid program, including benefits as a qualified Medicare beneficiary
(QMB) and a specified low-income Medicare beneficiary (SLMB).

QUESTIONS

If you lost or are losing other health
insurance coverage and received a notice from your previous insurer stating
that you were eligible for guaranteed issue of a Medicare supplement insurance
policy, or that you had certain rights to buy such a policy, you may be
guaranteed acceptance in one or more of our Medicare supplement plans. Please
include a copy of the notice from your previous insurer with your application.
PLEASE ANSWER ALL QUESTIONS.

[Please mark YES or NO below with an
"X"]

To the best of your knowledge,

(1) (a) Did you
turn age 65 in the last 6 months?

Yes
______No ______

(b) Did
you enroll in Medicare Part B in the last 6 months?

Yes
______No ______

(c) If
yes, what is the effective date? _____________________

(2) Are you covered for
medical assistance through the state Medicaid program? [NOTE TO APPLICANT: If
you are participating in a "spend-down program" and have not met your
"share of cost," please answer NO to this question.]

(d) Do you
receive any benefits from Medicaid OTHER THAN payments toward your Medicare
part B premium?

Yes
______No ______

(3) (a) If you
had coverage from any Medicare plan other than original Medicare within the
past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or
PPO), fill in your start and end dates below. If you are still covered under
this plan, leave "END" blank.

START ___/___/___END ___/___/___

(b) If you are still
covered under the Medicare plan, do you intend to replace your current coverage
with this new Medicare supplement policy?

Yes
______No ______

(c) Was this your
first time in this type of Medicare plan?

Yes
______No ______

(d) Did you drop a
Medicare supplement policy to enroll in the Medicare plan?

Yes
______No ______

(4) (a) Do you
have another Medicare supplement policy in force?

Yes
______No ______

(b) If so, with what
company, and what plan do you have [optional for direct mailers]?

____________________________________________________________________

(c) If so, do you
intend to replace your current Medicare supplement policy with this policy?

Yes
______No ______

(d) If so, what is
the paid-to or expiration date of your policy:___/___/___

(5) Have you had coverage
under any other health insurance within the past 63 days? (For example, an
employer, union, or individual plan?)